Defining near misses: Towards a sharpened definition based on empirical data about error handling processes

What is the effectiveness of reporting systems in promoting learning in healthcare?

Patient safety in healthcare remains a top priority. Learning from safety events is vital to move towards safer systems. As a result, reporting systems are recognised as the cornerstone of safety, especially in high-risk industries. However, in healthcare, the benefits of reporting systems in promoting learning remain contentious. Though the strengths of these systems, such as promoting a safety culture and providing information from near misses are noted, there are problems that mean learning is missed. Understanding the factors that both enable and act as barriers to learning from reporting is also important to consider. This review, considers the effectiveness of reporting systems in contributing to learning in healthcare.

Examining failure learning in online lending: Complete failure vs. incomplete failure

We examine the learning effects of borrowers’ failures in online lending. Based on funding ratios of borrowers’ loan listings in online lending, we first explore the role of failure degree in borrowers’ future funding performance. Further, we disaggregate borrowers’ funding failure into complete failure and incomplete failure, and compare theirs learning effects. Using a large sample of 610,000 online loan applications over six years from a Chinese leading online lending platform Renrendai, we use funding ratio to quantifiably measure each loan listing’s failure degree and conduct a series of tests. The results show that: (1) Borrowers’ failure degree of prior loan applications is negatively associated with one’s subsequent funding performance. (2) Borrowers’ complete failure cannot promote learning, while incomplete failure is good for future performance. (3) Both incomplete failure and complete failure interacted to influence the value of each type of experience and generate improved learning. Our results are robust across a variety of settings. The study sheds light for deeply understanding of failure learning phenomenon, and can also provide important implications for online lending managers to support successful financial transactions.

Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology

BACKGROUND

Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience ("we avoided failure") and vulnerability ("we nearly failed"). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting.

METHODS

A survey of radiation oncology department staff in an academic hospital assessed psychological safety and presented five scenarios with varying proximity to patient harm: "standard care" involving no harm, three near misses with varying proximity to harm ("could have happened," "fortuitous catch," "almost happened"), and one "hit" involving harm. Respondents evaluated each event as success or failure and reported willingness to report on a seven-point Likert scale. The analysis employed ordered logistic regression models.

RESULTS

A total of 78 staff (61.4%) completed the survey. The odds of reporting "hit" (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.19-3.23), "almost happened" (OR: 1.60, 95% CI: 1.07-2.37), and "fortuitous catch" (OR: 1.60, 95% CI: 1.10-2.33) improved with an increase in psychological safety. The relationship of psychological safety to reporting "standard care" and "could have happened" was not statistically significant. The odds of reporting were higher when a near miss was discerned as failure (vs. success).

CONCLUSION

Near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating health care workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.

Individual Circadian Preference, Shift Work, and Risk of Medication Errors: A Cross-Sectional Web Survey among Italian Midwives

Background: In order to explore the possible association between chronotype and risk of medication errors and chronotype in Italian midwives, we conducted a web-based survey. The questionnaire comprised three main components: (1) demographic information, previous working experience, actual working schedule; (2) individual chronotype, either calculated by Morningness–Eveningness Questionnaire (MEQ); (3) self-perception of risk of medication error. Results: Midwives (n = 401) responded “yes, at least once” to the question dealing with self-perception of risk of medication error in 48.1% of cases. Cluster analysis showed that perception of risk of medication errors was associated with class of age 31–35 years, shift work schedule, working experience 6–10 years, and Intermediate-type MEQ score. Conclusions: Perception of the risk of medication errors is present in near one out of two midwives in Italy. In particular, younger midwives with lower working experience, engaged in shift work, and belonging to an Intermediate chronotype, seem to be at higher risk of potential medication error. Since early morning hours seem to represent highest risk frame for female healthcare workers, shift work is not always aligned with individual circadian preference. Assessment of chronotype could represent a method to identify healthcare personnel at higher risk of circadian disruption.

[Influencing Factors and Consequences of Near Miss Experience in Nurses' Medication Error]

PURPOSE

This study aimed to predict the influencing factors and the consequences of near miss in nurses' medication error based upon Salazar & Primomo's ecological system theory.

METHODS

A convenience sample of 198 nurses was recruited for the cross-sectional survey design. Data were collected from July to September 2016. Using the collected data, the developed model was verified by structural equation modeling analysis using SPSS and AMOS program.

RESULTS

For the fitness of the hypothetical model, the results showed that χ² (χ²=258.50, p<.001) was not fit, but standardized χ² (χ²/df=2.35) was a good fit for this model. Additionally, absolute fit index RMR=.06, RMSEA=.08, GFI=.86, AGFI=.81 reached the recommended level, but the Incremental fit index TLI=.82, CFI=.85 was not enough to reach to the recommended level. With the path diagram of the hypothetical model, caution (β=-.29 p<.001), patient safety culture (β=-.20, p=.041), and work load (β=.18, p=.037) had a significant effect on the near miss experiences in nurses' medication error, while fatigue (β=-.06, p=.575) did not affect it. Moreover, the near miss experience had a significant effect on work productivity (β=-.25, p=.001).

CONCLUSION

These results have shown that to decrease the near miss experience by nurses and increase their work productivity in hospital environments would require both personal and organizational effort.

Digital health technology enhances resilient behaviour: evidence from the ward

Purpose

In the healthcare management domain, there is a lack of knowledge concerning the role of resilience practices in improving patient safety. The purpose of this paper is to understand the capabilities that enable healthcare resilience and how digital technologies can support these capabilities.

Design/methodology/approach

Within- and cross-case research methodology was used to study resilience mechanisms and capabilities in healthcare and to understand how digital health technologies impact healthcare resilience. The authors analyze data from two Italian hospitals through the lens of the operational failure literature and anchor the findings to the theory of dynamic capabilities.

Findings

Five different dynamic capabilities emerged as crucial for managing operational failure. Furthermore, in relation to these capabilities, medical, organizational and patient-related knowledge surfaced as major enablers. Finally, the findings allowed the authors to better explain the role of knowledge in healthcare resilience and how digital technologies boost this role.

Practical implications

When trying to promote a culture of patient safety, the research suggests healthcare managers should focus on promoting and enhancing resilience capabilities. Furthermore, when evaluating the role of digital technologies, healthcare managers should consider their importance in enabling these dynamic capabilities.

Originality/value

Although operations management (OM) research points to resilience as a crucial behavior in the supply chain, this is the first research that investigates the concept of resilience in healthcare systems from an OM perspective, with only a few authors having studied similar concepts, such as “workaround” practices.

Near Misses in Financial Trading: Skills for Capturing and Averting Error

OBJECTIVE

The aims of this study were (a) to determine whether near-miss incidents in financial trading contain information on the operator skills and systems that detect and prevent near misses and the patterns and trends revealed by these data and (b) to explore if particular operator skills and systems are found as important for avoiding particular types of error on the trading floor.

BACKGROUND

In this study, we examine a cohort of near-miss incidents collected from a financial trading organization using the Financial Incident Analysis System and report on the nontechnical skills and systems that are used to detect and prevent error in this domain.

METHOD

One thousand near-miss incidents are analyzed using distribution, mean, chi-square, and associative analysis to describe the data; reliability is provided.

RESULTS

Slips/lapses (52%) and human-computer interface problems (21%) often occur alone and are the main contributors to error causation, whereas the prevention of error is largely a result of teamwork (65%) and situation awareness (46%) skills. No matter the cause of error, situation awareness and teamwork skills are used most often to detect and prevent the error.

CONCLUSION

Situation awareness and teamwork skills appear universally important as a "last line" of defense for capturing error, and data from incident-monitoring systems can be analyzed in a fashion more consistent with a "Safety-II" approach.

APPLICATION

This research provides data for ameliorating risk within financial trading organizations, with implications for future risk management programs and regulation.

Connecting perspectives on quality and safety: patient-level linkage of incident, adverse event and complaint data

Background and objective

Incident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events, ultimately resulting in a complaint. This study examined relations between incidents, AEs and complaints that co-occurred in admissions.

Methods

Independently and routinely collected incident, AE and complaint data were retrospectively linked for surgical admissions in an academic centre (2008–2014). Two investigators reviewed whether incidents/AEs in admissions were clinically related and in what sequence (incident preceding vs following AE). Likelihood of occurrence of AEs and AE cascades (ie, ≥3 AEs) was studied using logistic regression analyses.

Results

Complaints were filed for 33 (0.1%) of 26 383 admissions. Complaints filed by patients with incidents and/or AEs (n=13) mostly addressed quality/safety problems, whereas other complaints mostly addressed relationship problems. Incidents and AEs co-occurred in 730 (2.8%) admissions, which seemed clinically related in 34% of these cases. Incidents with related AEs preceded as well as followed AEs (56.6%/44.4%). Patients with incidents were at greater risk of AEs than patients without incidents, even for seemingly unrelated AEs (OR 1.4; 95% CI 1.3 to 1.6). Risk of AE cascades was greater when patients with AEs also had incidents, regardless of whether these seemed related (unrelated: OR 2.0; 95% CI 1.6 to 2.5; related: OR 5.7; 95% CI 4.3 to 7.4) or whether incidents preceded or followed AEs in these admissions (53% vs 52%, P>0.05).

Conclusions

Patient-level linkage of incident, AE and complaint data can reveal relations between events that otherwise remain obscured, such as incidents that trigger as well as follow AEs, introducing event cascades, regardless of whether clinical relations seem present.

Enhancing the detection of injuries and near-misses among patient care staff in a large pediatric hospital

Objectives Compared to other industries, healthcare has one of the highest rates of non-fatal occupational injury/illness. Evidence indicates these rates are underestimated, highlighting the need for improved injury surveillance. This study aims to demonstrate the feasibility of integrating active data collection in a passive injury surveillance system to improve detection of injuries in a healthcare establishment. Methods Using digital voice recorders (DVR), pediatric healthcare providers prospectively recorded events throughout their shift for two weeks. This sample-based active injury surveillance was then integrated into an institutional surveillance system (ISS) centered on passive data collection initiated by employee reports. Results Injuries reported using DVR during two-week intervals from February 2014 to July 2015 were 40.7 times more frequent than what would be expected on the basis of the usual ISS reports. Psychological injuries (eg, stress, conflict) and near-misses were captured at a rate of 16.1 per 1000 days [95% confidence interval (CI) 14.1-18.3] and 35.6 per 1000 days (95% CI 32.7-38.8), respectively. Finally, 68% (95% CI 65-72%) of participants preferred using DVR either as an alternative or complement to the existing ISS. Conclusions This study showed that it is feasible to improve injury surveillance in a healthcare establishment by integrating active data collection based on voice recording within a passive injury surveillance system. Enhanced surveillance provides richer information that can guide the development of effective injury prevention strategies.

Safe Care for Pediatric Patients: A Scoping Review Across Multiple Health Care Settings

Children are particularly vulnerable to patient safety concerns due to pediatric-specific and general health care challenges. This scoping review identifies and describes the vulnerabilities of those aged 0 to 18 years to iatrogenic harm in various health care settings. Six databases were searched from 1991 to 2012. Primary studies were categorized using predetermined groupings. Categories were tallied and descriptive statistics were employed. A total of 388 primary studies exploring interventions that improved patient safety, deficiencies, or errors leading to safety concerns were included. The most common issues were medication (189 studies, 48.7%) and general medical (81 studies, 20.9%) errors. Sixty studies (15.5%) evaluated or described patient safety interventions, 206 studies (53.1%) addressed health care systems and technologies, 17 studies (4.4%) addressed caregiver perspectives and 20 studies (5.2%) discussed analytic models for patient safety. Further work is needed to ensure consistency of definitions in patient safety research to facilitate comparison and collation of results.

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

BACKGROUND

Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm because of mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence.

METHODS

Errors identified using video analysis were classified as errors of omission or commission and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared.

RESULTS

Thirty-nine resuscitations were reviewed, identifying 337 errors (range, 2-26 per resuscitation). The most common errors were related to cervical spine stabilization (n = 93, 27.6%). Errors of omission (n = 135) and commission (n = 106) were more common than errors of selection (n = 96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p = 0.03 and p = 0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p = 0.004 and p = 0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features.

CONCLUSIONS

Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Who falls in an adult emergency department and why-A retrospective review

INTRODUCTION

Falls are a significant source of healthcare related morbidity and mortality of patients in hospitals and residential healthcare settings. Commonly falls are thought of as an affliction of the elderly and the frail. The emergency department (ED) is a unique healthcare setting that sees patients in the acute and hyper acute stages of physical and mental illness and intoxication. Falls occur in this setting, however there is little knowledge about the factors that influence falls in the emergency department.

METHODS

This study was conducted in a large inner city, tertiary ED. Data was collected from the electronic incident management system for the period of time 2011-2015 and additional information was extracted from the patient's medical record.

RESULTS

During the study period a total of 190 fall incidents at a fall rate of 0.63 falls per 1000 presentations. 95.7% of these falls resulted in no or minimal harm to the patient. Patients who fell in the emergency department were younger them previously identified in other settings. The use of high-risk medications, recreational substances and alcohol was prevalent throughout the ED falls population. The most likely time for a patient to fall was during mobilisation, especially to the bathroom.

CONCLUSION

Falls occur in all healthcare settings, which include the ED. The cohort that falls in the ED is younger then in other settings and is more likely to have ingested recreational substances such as alcohol. A rethinking of falls risk specific to the emergency department needs to occur, along with further research into ED related falls.

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting

Introduction

Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches.

Methods

We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature.

Results

‘Fixing and forgetting’ was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients’ safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was ‘fixing and reporting’ mentioned as a way that the providers dealt with problems that they could resolve.

Conclusions

We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice.

Walk the talk: leaders' enacted priority of safety, incident reporting, and error management

PURPOSE

The main goal of the current research was to investigate whether and how leaders in health care organizations can stimulate incident reporting and error management by "walking the safety talk" (enacted priority of safety).

DESIGN/METHODOLOGY/APPROACH

Open interviews (N = 26) and a cross-sectional questionnaire (N = 183) were conducted at the Rotterdam Eye Hospital (REH) in The Netherlands.

FINDINGS

As hypothesized, leaders' enacted priority of safety was positively related to incident reporting and error management, and the relation between leaders' enacted priority of safety and error management was mediated by incident reporting. The interviews yielded rich data on (near) incidents, the leaders' role in (non)reporting, and error management, grounding quantitative findings in concrete case descriptions.

RESEARCH IMPLICATIONS

We support previous theorizing by providing empirical evidence showing that (1) enacted priority of safety has a stronger relationship with incident reporting than espoused priority of safety and (2) the previously implied positive link between incident reporting and error management indeed exists. Moreover, our findings extend our understanding of behavioral integrity for safety and the mechanisms through which it operates in medical settings.

PRACTICAL IMPLICATIONS

Our findings indicate that for the promotion of incident reporting and error management, active reinforcement of priority of safety by leaders is crucial.

VALUE/ORIGINALITY

Social sciences researchers, health care researchers and health care practitioners can utilize the findings of the current paper in order to help leaders create health care systems characterized by higher incident reporting and more constructive error handling.

Quality-related event learning in community pharmacies: manual versus computerized reporting processes

OBJECTIVE

To determine how staff assessment of key quality-related event (QRE) reporting process characteristics (e.g., ease of use, time to use) and QRE learning (e.g., extent that continuous improvement occurs) differ in community pharmacies in which the QRE reporting process is manual versus computerized.

DESIGN

Cross-sectional study.

SETTING

Nova Scotia, Canada, in 2010.

PARTICIPANTS

121 questionnaires completed by eligible respondents in pharmacies with a formal QRE reporting process.

INTERVENTION

Mail-based survey.

MAIN OUTCOME MEASURES

A list of key QRE process characteristics that affect error reporting was identified based on a review of the health care literature and piloted in 2009. The "learning from incidents" construct, as captured by Ashcroft and Parker, was used to assess QRE learning.

RESULTS

Regardless of process type, the key strengths of existing QRE reporting systems appear to be that they are cost effective, easy to complete, and involve low risk to operations. However, for almost all reporting and learning characteristics, staff assessments were different between the two pharmacy types (manual versus computerized QRE reporting process), with assessments being higher from staff working in pharmacies with a computerized reporting process.

CONCLUSION

A QRE reporting process with a notable computer or automated component may result in more positive staff assessment of various aspects of the reporting process and QRE learning.

Current assessment of patient safety education

The purpose of this literature review was to examine current evidence on how student nurses and nursing faculty members perceived the integration of patient safety education in preregistration/undergraduate nursing training. Databases searched from January 2000 to April 2011 included CINAHL, PsycINFO, British Nursing Index, PubMed, AMED, Academic Science, Midline, Cochrane Library Database, Web of Knowledge, Ovid Nursing Database, Wiley Online Library and Science Direct. In total, 77 articles were initially found, although only 15 were included in the author's review. Of these, 5 papers were research-based articles that examined aspects of patient safety education in undergraduate/pre-registration nursing training, and 9 papers were literature review and discussion based, which provided insight into the experience, assessment, evaluation or implementation of patient safety education curriculum in nursing education. The author's literature review highlights the continuing lack of research on patient safety education in undergraduate/preregistration nursing training and, in particular, outlines areas in nursing education which need to be addressed to develop patient-safety-friendly nursing curricula.

Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors

OBJECTIVE

To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death.

METHODS

In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher's exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women's relatives.

FINDINGS

In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives' accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group.

CONCLUSION

Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit

PURPOSE

To develop, conduct, and evaluate a proactive risk assessment (PRA) of the design and implementation of CPOE in an ICU.

METHODS

We developed a PRA method based on issues identified from documented experience with conventional PRA methods and the constraints of an organization about to implement CPOE in an intensive care unit. The PRA method consists of three phases: planning (three months), team (one five-hour meeting), and evaluation (short- and long-term).

RESULTS

Sixteen unique relevant vulnerabilities were identified as a result of the PRA team's efforts. Negative consequences resulting from the vulnerabilities included potential patient safety and quality of care issues, non-compliance with regulatory requirements, increases in cognitive burden on CPOE users, and/or worker inconvenience or distress. Actions taken to address the vulnerabilities included redesign of the technology, process (workflow) redesign, user training, and/or ongoing monitoring. Verbal and written evaluation by the team members indicated that the PRA method was useful and that participants were willing to participate in future PRAs. Long-term evaluation was accomplished by monitoring an ongoing "issues list" of CPOE problems identified by or reported to IT staff. Vulnerabilities identified by the team were either resolved prior to CPOE implementation (n=7) or shortly thereafter (n=9). No other issues were identified beside those identified by the team.

CONCLUSIONS

Generally positive results from the various evaluations including a long-term evaluation demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.

Catching and correcting near misses: the collective vigilance and individual accountability trade-off

Despite the focus on patient safety and quality health care for the last two decades, there is still limited understanding of how interprofessional interactions at an organizational or work unit level influence how clinicians perceive and respond to safety events and errors. Within the rubric of safety events, there has been a growing interest in near misses as precursors to adverse events in health care. Given the interactive nature of the variety of professionals working together in the delivery of health care, understanding how the different clinicians experience and respond to near misses in practice is important. A constructivist grounded theory approach was employed for this study which included semi-structured interviews with 24 participants in a large teaching hospital in Canada. Findings from this study provide a deeper understanding into how different clinicians experience and respond to near misses in clinical practice. This understanding indicates that collective vigilance can potentially create risk by eroding individual professional accountability through reliance on other team members to catch and correct their errors. Further research is needed to explore in more depth the trade-offs between collective vigilance and individual accountability by relying on others to catch and correct the potentially harmful errors and avert negative outcomes.